The present invention relates to a system and method for identifying high-risk members in a healthcare plan. More particularly, it relates to a system and method for using information from physician claims, facility claims, and pharmacy claims to identify high-risk members in a healthcare plan and to provide salient information on those members to an intervention agent.
For the past few decades, the predominant model of healthcare management used by most health care plans in the managed care industry has been one that focuses primarily on approving or denying coverage for medical procedures based upon specially developed criteria. This system has been subject to some criticism from doctors who feel that their treatment decisions should not be questioned, and from patients who feel that their health care plan places undue emphasis on financial consequences at the expense of sound medical care. Further, the current model employed by health care plans fails to place the appropriate amount of emphasis on proactive care. Studies have shown that an emphasis on proactive care can improve a health care plan member's overall health and well-being. Proactive care can also reduce the overall expense to a health care plan by replacing expensive medical procedures and treatments with less expensive proactive care activities.
Finally, under the current model, plan members commonly have minimal or no positive contact with their health care plan. Members pay health care premiums individually or through their employer and hope that, when treatment is needed, the health care plan will approve coverage. There is a need in the art for a health care management model that addresses the above shortcomings of the predominant current model. To implement a proactive-care-based or interventional model that allows a healthcare plan to take a proactive approach to providing health care to its members, it is necessary to have an effective system of identifying high-risk plan members or identifying plan members that are amenable to intervention (i.e., those members who can be helped with proactive or interventional care) and compiling relevant information regarding those members.
When a member of a health care plan receives care from health care providers, information regarding the care received is provided to plan administrators in documents commonly referred to as claims. Predominantly, this information is provided in the following three types of claims: physician claims, facility claims, and pharmacy claims. These claims are the documents that are submitted to the health care plan by physicians, hospitals, and pharmacies to receive reimbursement for care provided to the plan member. These documents generally contain coded data that provides information regarding the care received by the plan member. These claims are processed by the health care plan, and where appropriate, payment is transmitted to the health care provider.
For purposes of this specification, the phrase “physician claim” is used to refer to any professional service claim submitted to a health plan, typically on an HCFA-1500 form or its equivalent, and the phrase “facility claim” is used to refer to any facility claim. The phrase “medical claim” is used to refer to both physician claims and facility claims. Finally, the phrase “pharmacy claim” is used to refer to any claim submitted by a pharmacy or durable medical goods provider. Medical claims generally include codes for diagnoses and procedures relating to the plan member. The reason for the visit is typically represented by an International Classification of Diseases (“ICD”) code, currently in its ninth revision and thus commonly referred to as “ICD-9.” The description of the service provided in a medical claim typically takes one of two formats, a Common Procedural Terminology (“CPT”) code (promulgated by the American Medical Association), or a Health Care Procedural Code (“HCPC”) (promulgated by the Health Care Financing Administration).
The following materials serve as background for the present application and provide further information on some of the classification systems discussed: Physician's Current Procedure Terminology, CPT '94, published by the American Medical Association; HCPCS 1994 Medicare's National Level II Codes, published by Medicode, Inc.; Med-Index ICD9 CM Fourth Edition 1993, published by Med-Index, each of which is hereby incorporated by reference in its entirety.